Sofia Cano is struggling.
Ms. Cano is a 22-year-old transgender woman living in the custody of the South Carolina Department of Corrections. More than 4 years after the prison system’s own employees recorded her diagnosis of gender dysphoria, SCDC officials are stopping her from accessing medically necessary healthcare.
The ACLU of South Carolina, Baker Botts L.L.P., and Brooklyn Law School’s LGBTQ Advocacy Clinic recently filed a motion for summary judgment in a long-running court case seeking relief for Ms. Cano. The filing conveys the urgency of Ms. Cano’s need for medical care. It also paints a damning picture of the state prison system’s cruel and unusual mistreatment of transgender people.
“All we want is for SCDC to do what the Constitution demands: provide Ms. Cano with adequate healthcare,” said Meredith McPhail, staff attorney for the ACLU of South Carolina.
“SCDC’s blanket ban on hormone therapy, regardless of medical necessity, plainly violates the Eighth Amendment,” said Scott Novak, an associate at Baker Botts. “It’s a shame SCDC chooses to waste taxpayer dollars defending discriminatory policies instead of giving people like Ms. Cano the medical care they deserve.”
“SCDC’s policy is discriminatory and unfair,” said Prof. Susan Hazeldean, Director LGBTQ Advocacy Clinic at Brooklyn Law School. “It singles out transgender prisoners and denies them medical care regardless of their needs. Sofia Cano is suffering tremendous pain every day because of this ban. She is fighting for change not only for herself, but to improve the lives of all trans people in SCDC custody.”
The state of gender-affirming healthcare in S.C. prisons
South Carolina Department of Corrections (SCDC) policy provides that incarcerated people will receive “medically necessary care . . . throughout their incarceration . . . in keeping with generally accepted medical standards of the community.” SCDC pays for medically necessary care, with an exception for only one diagnosis: gender dysphoria.
Under a “freeze-frame” policy, SCDC does not purchase or prescribe medications for hormone replacement therapy to treat gender dysphoria unless the incarcerated person was using the medication prior to incarceration. This sets up an absurd double standard where, for example, patients can receive Estradiol for osteoporosis or Spironolactone for hypertension, but those same medications are forbidden to people with gender dysphoria who were not already receiving them.
About 30 transgender women are currently incarcerated in SCDC custody. After months of discovery and depositions of SCDC employees, Ms. Cano’s legal team describes the ways that South Carolina prisons have failed to meet transgender people’s most basic needs for safety and wellbeing.
SCDC employees know that transgender incarcerated people suffer when they are denied healthcare such as hormone therapy, the simple dignity of being called by their names, or basic accommodations like hair removal products. They have seen this suffering firsthand: other patients suffering from gender dysphoria in SCDC have considered and even attempted self-surgery.
SCDC employs a Transgender Service Coordinator. When the legal team deposed that employee, she stated that she first heard the term “transgender” after Googling it and reading “[w]hatever popped up” when she first “applied for the position.” She received no other training at the time she began the job.
Internal training documents for SCDC employees reference internationally recognized standards of care for transgender incarcerated people from the World Professional Association for Transgender Health (WPATH). But the prison system routinely ignores those standards of care, which explicitly condemn blanket bans on hormone therapy and recommend that prison staff address trans individuals by their chosen names and allow them to request gender-appropriate canteen items.
Sofia’s story
The latest motion for summary judgment lays out a number of undisputed facts. One of the key facts is Ms. Cano’s diagnosis of gender dysphoria, which is mentioned over and over again in records kept by SCDC.
Since July 2020, when a mental health care provider employed by SCDC documented Ms. Cano's diagnosis of gender dysphoria, the prison system has known that Ms. Cano has a serious medical need. In a violation of Ms. Cano’s 8th Amendment rights, SCDC has cruelly denied her care for more than 4 years now.
Prison officials recognize that Ms. Cano legally changed her name to Sofia in 2021. But SCDC staff routinely misgender her to this day and force her to wear a badge with her former name on it. This is a needlessly humiliating ordeal, and it goes against the WPATH Standards of Care.
Staff working with Ms. Cano have heard her describe “persistent thoughts of death” due to her gender dysphoria. SCDC staff also know that Ms. Cano attempted auto-castration. In June 2021, a qualified mental health professional recommended that Ms. Cano “should continue to be assisted in her gender transition.”
In January 2023, the U.S. District Court for the District of South Carolina ordered SCDC to evaluate Ms. Cano’s need for hormone therapy and, if necessary, to provide it. Prison officials chose a psychiatrist who had never initiated hormone therapy for any patient and who had not reviewed the WPATH Standards of Care for incarcerated people.
That psychiatrist indicated, without explanation, that Ms. Cano did not need hormone therapy. When deposed, the psychiatrist claimed that Ms. Cano did not have gender dysphoria because there was “no evidence of distress,” despite Ms. Cano’s own statements, Ms. Cano’s extensive medical records, and the findings of several other clinicians.
Part of a broader struggle
Ms. Cano is struggling. In recent months she has had daily thoughts of suicide. She has struggled to sleep and has lost the ability to concentrate on simple activities like reading or watching TV. Even activities that usually bring her joy, like teaching classes to fellow incarcerated people or playing tabletop role-playing games with friends, have become a struggle because of the distress she feels about how people perceive her body.
Over the course of Ms. Cano’s prolonged fight to access healthcare, SCDC has offered shifting rationales for denying her care. First, the department based its decision on an interpretation of state Budget Proviso 65.28, which they argued prevented the use of state funds to begin individuals on hormone therapy.
After a court rejected that argument in January 2024 and ordered SCDC to evaluate Ms. Cano's need for hormone therapy, SCDC changed its tune, arguing that Ms. Cano does not have gender dysphoria at all—despite reams of documentation from the prison system’s own healthcare providers saying that she does.
SCDC’s refusal to treat Ms. Cano’s medical condition is cause for alarm. It violates the 8th Amendment prohibition on cruel and unusual punishment, and it violates the 14th Amendment Equal Protection Clause. To read more about this ongoing case, visit the case page for Cano v. South Carolina Department of Corrections. To learn more about Sofia’s personal journey, see our blog post, “A trans South Carolinian fights for fair treatment behind bars.” And finally, to read about the ACLU-SC's separate case seeking the right to publish Ms. Cano’s story in her own words, see ACLU-SC v. Stirling.
